Maggie McKay (Host): Welcome to Conversations Like No Other, presented by Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad, everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm your host, Maggie McKay.

If getting pregnant has been a plan or a goal of yours and it's not happening, it's normal to feel grief, stress, or anxiety. Infertility is a term used for not being able to get pregnant after a year of trying to conceive, or six months if you're over the age of 35. There are many treatments to consider depending on your personal story. Joining us today is Dr. Keri Greenseid, reproductive endocrinologist and infertility specialist to discuss fertility. Thank you so much for making the time to be here today.

Keri Greenseid, MD: Thank you for having me.

Host: Absolutely. Let's just start with what's the most common reason women cannot get pregnant?

Keri Greenseid, MD: So, the answer to this question can vary based on patient population. Overall, ovulatory dysfunction is the most common single identifiable cause for female infertility. But in general, difficulty getting pregnant can be due to female factors, male factors, a combination of issues or even unexplained where no reason is found. I think it's helpful to go through some of the different factors that it can affect both females and males.

 Regarding female infertility, difficulty conceiving can be due to ovulatory disorders such as polycystic ovary disease or hormonal imbalances, premature ovarian failure, or something called hypothalamic dysfunction. Additional female factors can include tubal blockage or tubal disease where the fallopian tubes may be damaged. Uterine factors such as fibroids or polyps, uterine scarring or congenital anomalies, endometriosis or diminished ovarian reserve, which describes a decrease in egg quantity and potentially egg quality.

 Some of the male factors can include abnormal sperm volume, count, motility or morphology, which is a term that's used to describe the shape of the sperm. Men can also be impacted by a varicocele, which is a dilated blood vessel in the scrotum that can impact the sperm parameters. And men can also have obstructed sperm ducks or experience erectile or ejaculatory dysfunction. And as I mentioned earlier, there can be a combination of these factors and there can also be something called unexplained infertility where we cannot identify a cause, and this can account for up to 15-30% of infertility cases.

Host: Are there any lifestyle reasons causing infertility?

Keri Greenseid, MD: Yes. Lifestyle factors can definitely contribute to infertility. The strongest evidence supports the effects of body weight, smoking, alcohol consumption, and dietary patterns. And getting into a little bit more detail, obesity can impact both male and female infertility. So, obesity has been associated with a higher incidence of difficulty, ovulating and dysfunctional ovulation, a higher incidence of metabolic changes and lower rates of success with infertility treatment and higher miscarriage rates.

We always encourage lifestyle modifications, working with diet, exercise, weight loss, and nutritionist consultations when taking on fertility treatment in the obese population. In some cases, we even talk to some couples about preserving their fertility by cryopreserving eggs or embryos so they can take some time to pursue weight loss. And this can be really helpful when women are of older maternal ages or have a low egg reserve and their fertility may be declining, and they want to take the time that's needed to pursue the weight loss and increase their chances for having a safe and healthy pregnancy after weight loss.

And as I mentioned, in addition to weight, smoking and alcohol intake can also negatively impact fertility as well as environmental factors such as exposure to chemicals, plastics, BPA, or a history of exposure to chemotherapy or radiation.

Host: You mentioned older maternal women and that's what, 35 and above. Because I remember when I was pregnant and, on my file, it said senior mom. I said, "What? What is that?" And they're like, "If you're over 35, you're a senior mom." I'm like, "Okay." But they just scared you so much because 35, they were acting like you were 65. Is that kind of the common date that doctors say is sort of on the edge of older, 35?

Keri Greenseid, MD: Yes, the terminology is not fair. I agree with you, but that is the age where we start to see lower pregnancy rates, higher miscarriage rates, and higher rates of genetic abnormalities. So, that's where that age comes into play.

Host: So if I'm trying to get pregnant and, month after month, I don't. Do I need to wait a whole year before I see a doctor?

Keri Greenseid, MD: So, you don't. The truth is if you are under age 35, we typically recommend initiating a workup after you've tried for 12 months and haven't had success; and if you're 35 years of age or above, to begin that workup after six months of trying. However, earlier evaluation can often be recommended in many circumstances such as when a female has ovulatory dysfunction or irregular menstrual cycles, if they have a history of tubal disease or endometriosis, if they have a history of exposure to chemotherapy or radiation, or if there are some suspicion for male factor. We want to see these patients earlier. They certainly don't need to wait the full year. We also know that our single patients or same-sex couples who are planning pregnancy using a donor gamete are also seen when they're ready to pursue pregnancy or even before for preparation.

Host: What's a donor gamete?

Keri Greenseid, MD: A donor gamete refers to donor eggs or donor sperm. So if I have a single female or a same-sex female couple, they may be interested in pursuing pregnancy using donor sperm. So, they're going to come to me in preparation for that process so we can get everything ready for them to get pregnant.

Host: Okay. If I see a fertility specialist, what does a typical appointment look like?

Keri Greenseid, MD: So, the typical appointment begins with a history and a physical exam. So during the history, we really delve into how long a couple has been trying, any difficulty that they've been having during the trying process. And we look into any prior pregnancies that they've had, whether successful or unsuccessful; their gynecological history, their menstrual history, medical and surgical history, any medications that they take, family history and social history, because all of these things can key us into what may be causing them difficulty getting pregnant. We then typically do a physical exam and a pelvic ultrasound. And then, we begin to discuss the workup, which is really individualized to each couple or patient.

The basic workup involves assessing egg quantity. And we check that with looking at hormone assessment and an ultrasound at the beginning part of a woman's menstrual cycle. And again, we're doing this to assess their egg quantity. We also assess the uterine cavity and fallopian tubes with a test called a hysterosalpingogram or an HSG test. And that allows us to see if the fallopian tubes are open and if the uterine cavity has anything inside that could be preventing an embryo from implanting. We look to confirm ovulatory activity And we also check the sperm parameters. During this initial visit, we also talk about a preconception genetic testing option to see if a couple may be at increased risk for certain genetic disorders in their offspring.

Host: Dr. Greenseid, do you have any suggestions for how I can respond to nosy parents and friends when they ask why I don't have kids yet?

Keri Greenseid, MD: This can be a real problem. And people can be so insensitive. So, I do have some suggestions for these situations. And I also spoke to my reproductive psychologist, Dr. Kim Weiss, who also consults with many of my patients to help handle some of these encounters. And we both agree that there's no right answer, and it's really dependent on the relationship and the comfort of the patient.

 The first thing I tell my patients is to think about who's asking? Is this a well-meaning grandmother or is this a competitive sister-in-law? Because your response might be different depending on who's asking the question. Some patients really want to remain private and they might feel most comfortable changing the subject, not even responding, and just say, "So, what's going on with you?" Some people. Who are maybe more comfortable with a confrontation might just say with a smile, "Hey, that's a little personal." And some might choose to be honest and say, "We're working on it," or "I hope soon," or "I wish I knew." But I think it's important for patients to remember you don't owe anyone any information or an explanation, but sometimes sharing might make you feel better. Sometimes sharing might get them to stop asking. So, I think we really just have to individualize each one of these cases.

Host: So, how can I cope with the stress of not getting pregnant? Because that is one emotional rollercoaster.

Keri Greenseid, MD: Absolutely. You're so right. I think having a strong support system can be helpful, potentially partner, friends, sibling or parent, somebody that you can talk to. There are also support groups, both online and in person, that some people also find very helpful, Meeting with a reproductive psychologist or a therapist, cognitive behavioral therapy and certain mind-body interventions have also been shown to improve outcomes. Cognitive behavioral therapy can work on things like relaxation techniques, restructuring patient's thoughts and eliminating negative automatic thinking, which can be as effective or even more effective than certain medications. Acupuncture is another element that's shown some promise as a complementary approach to handling some of the stress.

Host: And can stress cause infertility?

Keri Greenseid, MD: Stress can be contributing to infertility. Absolutely. Some of the studies have conflicting results in this area. And sometimes stress is a difficult marker to measure when you're performing an academic study. But we do know that stress can impact libido. It can impact al frequency, or how often a couple is having intercourse. It can also increase cortisol production, which can impact ovulation. So, stress can certainly impact our ability to get pregnant.

Host: Dr. Greenseid, what's the first step in getting pregnant after intervention?

Keri Greenseid, MD: Okay. So, this is definitely not a one-size-fits-all answer. It definitely is going to depend on the workup, and it also often depends on a patient's age. So, we have to factor in all of these options. When we think about treatment options, there's a progression from less involved to more involved in terms of medications, procedures, side effects, and pregnancy rates.

So, I think it's important to review and make these decisions with all the necessary information. So, we talk about the results from a couple's workup, the age of the patient, potentially factoring in what their insurance benefits are as well as what the patient is comfortable in pursuing in terms of treatment.

 But in general, treatment options include monitoring a patient for their natural ovulation and helping them time intercourse, inducing ovulation in patients who are not ovulating on their own, and potentially triggering them to ovulate so that we could time intercourse precisely as well as add on intrauterine insemination. And then, in certain scenarios, or if other treatments are not successful, we consider treatment with in vitro fertilization and the option of pre-implantation genetic testing, which allows us to test the genetics of an embryo prior to getting somebody pregnant. So, sometimes there's a sequential course that we take where we try lesser means. And if that's not successful, we move along in the progression. However, sometimes if we find that a patient has blocked fallopian tubes or their partner has a severe male factor in vitro fertilization may be our first step.

Host: What about miscarriages? If you have a history of miscarriages, does that mean you can't get pregnant?

Keri Greenseid, MD: Absolutely not. Unfortunately, miscarriages are relatively common. When a patient has a history of one prior miscarriage, their chance of a successful subsequent pregnancy approaches the same chance as if they had only had a live birth previously. After two miscarriages, the probability of a successful pregnancy still remains high. Maternal age significantly impacts the likelihood of miscarriage. And so, we really have to individualize each case. But the answer to your question, does a miscarriage mean I can't get pregnant? Absolutely not.

Host: That's very encouraging to a lot of people listening, I'm sure. What about insurance coverage? Does insurance cover treatment?

Keri Greenseid, MD: Again, not a one-size-fits-all answer, but insurance does cover quite a bit of treatment, especially in the state of New Jersey. So, we have a finance department or a billing department within our practice. And we can check patient's insurance benefits as soon as they provide their insurance information. So, we can do this before they even confirm their appointment, which is nice, so people understand what type of benefits they do have.

Host: And how can I get my partner to agree to be tested for his potential infertility? Because that might be an awkward conversation.

Keri Greenseid, MD: It sometimes is. I think the best way is to explain to partners that fertility can be impacted by both male and female factors as well as unexplained causes. And the only way that we can figure out if there is an issue and properly pursue treatment is by completing that workup. And I also tell patients that if you're really having trouble talking to your partner about it, see if they can come in for your appointment or have an appointment with me so that I can explain these factors to them.

Host: That's a good idea. In closing, is there anything else you'd like to add that maybe we didn't cover?

Keri Greenseid, MD: I think that I would encourage all patients if they are interested in having a family and having any difficulty to definitely seek an evaluation with a reproductive endocrinologist and infertility specialist. Pregnancy success rates are improving all the time, and I think the best thing that patients can do is to come in for an evaluation and discuss all of their options.

Host: Thank you so much for sharing your expertise. This has been so informative and helpful. We really appreciate it.

Keri Greenseid, MD: Thank you for having me.

Host: Absolutely. Again, that's Dr. Keri Greenseid. For more information about the Valley Hospital Fertility Center, please visit valleyhealth.com/fertility. Thanks for listening to Conversations Like No Other, presented by Valley Health System in Paramus, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-634-5400-- that's 201-634-5400-- or email valleypodcast@valleyhealth.com.